The essay examines a situation encountered by the student during her placement on a hospital ward: the regular ward meetings to discuss patient care and progress. The essay reflects upon the experience using the reflective cycle model proposed by Gibbs. It also draws upon SWOT analysis and the PDSA cycle model for nursing practice. While rooted in the student’s experience, the essay also looks at relevant theoretical concepts including those of multidisciplinary teamwork and patient-centred healthcare.
This essay aims to consider a situation I have encountered during my placement, using principles of reflective practice to outline an appropriate change to established procedure which, I feel, will benefit service users and staff. I want to discuss ward reviews, and show how these can be improved by extending the range of people who attend these reviews.
I want to use principles of reflective practice and evidence-based practice to examine this area. The essay will use Gibbs reflective cycle as a structure within which to understand a situation I encountered, and plan for change. The essay will also look at some relevant theory, including notions of interprofessional team work, change theory and team dynamics.The current situation will be discussed in terms of these. I will also draw upon the PDSA cycle model for nursing practice (NHS Institute for Innovation and Improvement 2012 [online]), which provides a way to structure and implement change. I will also use a tool widely used in business called ‘SWOT’ analysis, which helps in change planning by formalising the strengths, weaknesses, opportunities and threats in a given situation, and which is also useful for healthcare (Marquis and Huston 2009). Gibbs (1988) model of reflective practice will also be influential. The essay will be structured according to this 6 stage cycle, from description of event through evaluation and analysis to action and further reflection. While there are several different models of using reflectivity in practice including Bortons’ (1970), Kolb’s (1984) and Johns’ (1995), I use Gibbs model as it seems to best express the dynamic process of learning and change for me.These tools will be used to demonstrate the things I feel are inadequate with the present situation whereby a limited number of healthcare professionals attend ward reviews, and suggest a change whereby key workers also attend, offering a deeper perspective on patient needs.
The nomination form, which assesses my placement, is included in the Appendix.
2. The Situation: Description
The situation in question occurred when I was on placement. The hospital at which I was working, like others, carried out regular ward reviews. In these, the patient was discussed. A number of key staff involved in patient care were involved, and the aim was to review the patients care, treatment and prognosis. At the hospital where I carried out my placement, the members of staff who were involved were the consultant, the occupational therapist and the review nurse, sometimes also a student attended. The patient did not attend this meeting. I attended a number of these reviews. In general, all members of the team who attended were respected and respectful, and took care to listen to what each person had to say. One person led the meeting, making sure all were included and also ensuring that discussion did not go on for too long. Realistic goals and a date for the next meeting were set at the end, and the items discussed were formalised in writing.
3. The Situation: My Feelings
I had two sets of feelings. On the one hand, I felt pleased that everyone who attended the meetings seemed to have the best interests of the patient at heart. Where there were disputes it was regarding what would work best for the patient. Also, I was pleased with how professionally staff members conducted themselves, I seldom witnessed rudeness or ‘shortness’ when one person spoke to another. People took turns and really seemed to listen. In part, I felt, this was due to the way the meetings were led, which was very sensitive. However, on the other hand, I felt quite annoyed and disappointed that not all staff who were involved in patient care were included in the meetings. I felt that a whole side of the patient’s experience was being missed out. The staff who attended seemed to understand the patient’s condition only generally, from their records and discussing the situation, not through contact with the patient daily. The holistic side of patient care, understanding what the patient was feeling, seemed to have been missed out.
In terms of the ‘SWOT’ framework, widely used in business but also useful for understanding healthcare (Williamson et al 1996), I evaluated the experience as follows. As Gibb’s evaluation stage is concerned mainly with what is good and bad about the experience, I have omitted the ‘opportunities’ and ‘threats’ from this analysis, as they will be covered later.
Good communication between team members
Respectful awareness of other points of view
Developed clear goals and actions to follow
Patient seems to lack a ‘voice’
Those involved in caring regularly from patient are not included in the review
Those who know the patient well are not included in the review
Lack of holistic and person-centred care
The following sections looked at what happened, how I experienced it and what sense I made of it within my own parameters. In order to make wider sense of the situation, I need to draw upon notions of interprofessional teamwork, user perspectives and team dynamics, all concepts central to the current health service. Interprofessional teamwork, also known as multidisciplinary teamwork (MDT), has been part of healthcare policy in the UK since 1997 (Davis 2007). As an approach, it means professionals from a range of disciplines involved in patient care meeting to discuss and agree on care plans for patients (Hostad 2010). There are a number of benefits, for example multidisciplinary teamwork seems to meet user needs better, and to deliver better outcomes. However, there are also some drawbacks including the time needed for teams to work effectively, and difficulties with perceived status differences (Housley 2003).For effective MDT, the ways in which team dynamics work has to be understood. There are many attempts to understand how people work together, both generally and in the healthcare context, for example Bale’s (1950) model. Maslow’s model is also influential in healthcare. He suggested that all human’s need to be respected by others in order to feel valued, and have a need to feel part of a group, and want to have their social and emotional needs met within the work context (Borkowski 2009).
The notion of incorporating user perspectives is also very influential in the NHS currently, as ‘patient-centred healthcare’. This was introduced in the late 90’s, and involves patients being involved as much as possible in decisions which are made about their care. The relationship between healthcare professional and patient is no longer one in which the professional is at the top of a hospital hierarchy, but one of partnership in which mutual respect and communication exist (Chambers et al 2003)
Overall, I feel that both MDT and patient-centred healthcare could be improved here through including the key workers, or support workers of the named patient. The key worker acts as a co-ordinator on behalf of the patient, keeping the patient informed of what is going on and co-ordinating care and ensuring continuity of treatment (NICE 2004). Support workers or healthcare assistants act in a supporting role to other professionals, and are very ‘hands-on’ in well-being and looking after the patient.Both these professionals have much closer contact with the patient and as such have important insights into the patient’s situation. Multidisciplinary teamwork emphasises including all viewpoints relevant to the situation, and I feel that these workers would add valuable insights to enhance the teamwork. In addition, how can patient care be really holistic and patient-centred if the meetings do not include those people who get to know patients as individuals, understanding their feelings, hopes and fears Including support and key workers would allow those people who are not involved in daily care to really understand how the patient is feeling.In addition, if support and key workers were present at the meeting, it would be much easier and quicker to feedback to the patient what is going on with their care. As it stands, patients hear second hand.
Gibbs suggests reflecting upon what else I could have done here. Given that I was on placement, I feel that the opportunities for changing the situation are practically limited. At the time, I felt it was not appropriate for me to speak up and question the accepted meeting structure. Later, however, I did question whether I should have mentioned this to my supervisor on the ward. I felt that the emphasis on MDT meant that I would be heard sympathetically, even though I had very little experience.
If I was able, I would change the meeting structure to ensure that either a support worker or a key worker was included as a matter of principle. I feel that the existing meeting structure is very good, and that if it was part of protocol that staff closely involved in the patient’s care were included, they would be welcomed into the meetings, their opinions heard and the patient’s viewpoint better understood. This would, I feel, ensure that the care delivered to the patient was more truly patient-centred and holistic, as it would take into account not only quantitative data about their condition but also their feelings and emotions. In addition, I feel wider meetings would be more reflective of multi-dimensional teamworking, as they currently don’t include all staff perspectives.
It also seems that including key and support workers is more ethical. All hospitals have detailed code of conducts which set out the ways in which they expect their staff to behave, and the care of the patient is generally the first priority in these. Working as a team is also one of the central tenets of most ethical codes in UK hospitals (Melia 2004).
7. Action Plan
Here I draw upon the PDSA model to suggest a way to structure the change:
Discuss and agree new format for meetings (including key worker or support worker)
Inform key / support worker and other staff of new meeting format
Carry out a series of 4 pilot meetings over agreed time period
Agree and implement mechanisms for review of new meeting format (gather data from key/support workers, staff already included, and patients)
Analyse data collected, assess changes against clearly defined criteria (for example, do patients feel more informed, happier; did key/support workers feel included; did other staff value new structure)
What worked wellWhat worked less well?
Plan new meetings on basis of what was learnt during study phase. If including key/support workers beneficial, change meeting structure so that they are now part of meetings. Ensure that repercussions of this are understood, for example allowing them extra time for preparing for meetings.
Borton, T (1970) Reach, Teach and Touch, Mc Graw Hill, London.
Gibbs, G (1988) Learning by Doing: A Guide to Teaching and Learning Methods, Further Educational Unit, Oxford Polytechnic, Oxford.
Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing Journal of Advanced Nursing, 22, 226-234
Kolb, D A (1984) Experiential Learning experience as a source of learning and development, Prentice Hall, New Jersey
Marquis, B L and Huston, C J (2009) Leadership roles and management functions in nursing: theory and application (6th edn), Lippincott Williams & Wilkins.
Melia, K M (2004) Health care ethics: lessons from intensive care, SAGE, Thousand Oaks, CA
NHS Institute for Innovation and Improvement (2012) ‘Plan, Do, Study, Act (PDSA)’, [online] (cited 14th February 2012), available from
NICE (2004) ‘Improving Outcomes Guidance for Supportive and Palliative Care’, National Institute of Clinical Excellence 2004, London.
Williamson, S, Stevens, R E, Loudon, D L (1996) Fundamentals of strategic planning for healthcare organizations, Routledge, UK
CLIENT – INCLUDE NOMINATION FORM HERE
In writing the 1500 word reflective commentary focussed on service improvement you should consider/address the following:
The context and setting for your placement.
Your reflective commentary should focus either on a service improvement initiative that you have identified with your mentor, or on a service improvement that has previously been implemented in your practice area. You should examine this initiative in terms of the inter-professional team and identify actual or potential ways that inter-professional working can facilitate its implementation. You should also discuss potential barriers to implementation.
You MUST include the Service Improvement Activity notification form with your assignment including a discussion of future plans in terms of the service improvement initiative.
An evidence based model of reflection or reflective writing should be used. You should offer a rationale to support what you have used (fixed resource sessions on the use and application of reflective models and writing are included in the delivery of this module). You should also demonstrate the use of the PDSA cycle in terms of service improvement. For assessment purposes you are not expected to move beyond the planning stage of the PDSA cycle.
As this assignment is a reflective commentary your reflection must be supported and referenced by using appropriate sources (as per learning outcomes). You may wish to use a structured reflective model e.g. Gibbs’, Rolfe et al or John’s; or you may wish to write in a reflective style, encompassing reflection on action e.g. Schon or Borton. This is your choice but either way you must show evidence you have done this.
A reflective commentary requires that you use subheadings. The structure of this piece of work can be informed by using either learning outcomes or the stages of a reflective model to do so.
If you say you are going to use a model of reflection, then you must demonstrate clearly that you have done so.
Which ever process you use must be briefly explained and rationalised within your introduction.
Ensure that you have supported your assignment with appropriate, contemporary and relevant sources, including published literature, professional standards key texts and policy.
You need to apply theory to practice and use paraphrasing to demonstrate understanding of the sources you have used.
Make sure you address the relevant learning outcomes for this piece of work (l,2,5) in this commentary:
Learning outcome one requires you to analyse the unique role of the nurse within the inter-professional team and also to apply this to your experience in your placement area. For example, do nurses in your placement area require any additional skills or knowledge to work with the client/patient group
Learning outcome two requires you to evaluate the contribution of all members of the inter-professional team in providing holistic care to clients/patients. For example, which guidelines and policies inform holistic care in your placement area and how did this impact on practice in your areaHow did the team work togetherWhat qualities did you note in the team and how did this impact on care delivery
Learning outcome five asks you to reflect on learning and transfer newly gained knowledge. For example, what did you learn and how will what you learned in your placement help to prepare you to be a registered nurse